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 19

Hard and Soft Tissue Augmentation in a

Postorthodontic Patient: A Case Report

Fred J. Bonacci, DMD* Orthodontic tooth movement may

lead to the development of hard and
A combination of hard and soft tissue grafting is used to augment a thin biotype. A soft tissue defects and is dependent
26-year-old woman with mandibular anterior flaring and Miller Class I and III recessions on bone volume and the ideal tooth
requested interceptive treatment. Surgery included a full-thickness buccal flap, intramarrow position.1 Alveolar bone dehiscences
penetrations, bone graft placement, and primary flap closure. Postoperative visits were
and fenestrations in general can be
at 2 and 4 weeks and 2, 3, and 6 months. Stage-two surgery consisted of submerged
associated with root prominence and
connective tissue graft placement. Postoperative visits were completed at 2, 4, 6, and 8
weeks and 1 year. Follow-up was completed 3 years after the initial surgery. Interradicular
can affect alveolar bone thickness.
concavities were resolved and gingival biotype was augmented. Soft tissue recession Rupprecht et al1 found a positive
remained at 6 months. Reentry revealed clinical labial plate augmentation; 2 mm was correlation between the presence of
achieved at the lateral incisors and the left central incisor and 3 mm was achieved at the bone dehiscences and fenestrations
right canine. No bone augmentation was achieved on the left canine and right central and thin alveolar bone.
incisor. The dehiscence at the right central incisor appeared narrower. Overall, a 2- to 3-mm Knowing the ideal or final tooth
gain in alveolar bone thickness/height was observed. Two months after stage-two surgery,
position and soft tissue character-
near complete root coverage was achieved; 1 mm of recession remained on the left
istics is useful during orthodontic
central incisor. There was a soft tissue thickness gain of 2 mm without any visual difference
in keratinized tissue height. Interradicular concavities were eliminated; the soft tissue was
treatment planning. Steiner et al2
augmented and the gingival biotype was altered. Interdental soft tissue craters remained. suggested that tooth position is an
One year after connective tissue graft placement, there was near complete root coverage important factor in gingival reces-
at the left central incisor, which at 2 months experienced residual recession. Interradicular sion. If the facial plate is thin and the
concavities and interdental soft tissue craters were eliminated with soft tissue augmentation, teeth are moved labially, significant
including clinical reestablishment of the mucogingival junction. Clinical stability remained apical migration of the junctional
3 years after the initial surgery, with the patient noting comfort during mastication and epithelium and reduction in the facial
routine oral hygiene. A clinical increase in labial plate thickness, in conjunction with soft
apicocoronal bone height are noted.
tissue augmentation, appears to provide for continued stability and decreased potential
This is followed by apical migration
for future clinical attachment loss. (Int J Periodontics Restorative Dent 2011;31:1927.)
of the marginal gingiva. Thus, sig-
nificant proclination of the teeth is
*Diplomate, American Board of Periodontology; Private Practice, Dunmore, Pennsylvania; correlated to the development of
Former Resident, Department of Periodontology, Tufts University School of Dental Medicine, soft tissue defects. Maynard3 sug-
Boston, Massachusetts.
gested that the apicocoronal width
Correspondence to: Dr Fred J. Bonacci, 1039 ONeill Highway, Dunmore, PA 18512; of the attached gingiva is important
fax: (570) 344-3359; email: bonacciperio@verizon.net. in relation to orthodontic treatment.

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20
Wennstrm et al4 also addressed this
matter. They suggested that plaque-
induced inflammation and marginal
soft tissue thickness (volume) were
determining factors for the develop-
ment of gingival recession, as well as
clinical attachment loss in relation to
orthodontic tooth movement. The is-
sue of thick versus thin biotype also
plays a crucial role in potential soft
tissue recession.
Two potential treatment options
for addressing these clinical situations
exist. The first is guided tissue regen-
eration (GTR)based root coverage.
The original concept of cell exclu-
sion stemmed from Melcher,5,6 who
suggested that the type of cell that
repopulates the exposed root surface
will define the nature of the attach-
ment or repair that takes place. These
cells originate in either the periodon-
tal ligament or the alveolar bone.
Proper tissue handling is important,
as well as determining if bone graft
addition or barrier membrane use is
indicated. If chosen, use of a graft
material with osteoinductive poten-
tial is crucial. Bowers et al7 suggested
that demineralized freeze dried bone
allograft (DFDBA) has an osteoinduc-
tive capacity because of the bone
morphogenic proteins it contains.
These key concepts aid in the desired
tissue regeneration. Al-Hamdan et al8
concluded that GTR-based root cov-
erage was successful in repairing gin-
gival recession defects. In addition, it
was suggested that membrane use
improved the outcome, but there
was no statistical benefit to the addi-
tion of a bone graft material.
The second treatment option
is placement of a subepithelial con-
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nective tissue graft (CTG). A classifi-
cation of gingival recession defects
was established by Miller9 that ad-
dressed certain aspects of attached
gingiva and interdental bone height.
Langer and Langer10 developed a
technique, later modified by Bruno,11
by which a CTG can be harvested
from the palate and used to achieve
root coverage. A modification de-
scribed by Lorenzana and Allen12
uses a single incision donor site de-
sign, which was used in this report.
This transplanted tissue contains
cells that are suggested to stimulate
keratinization of the overlying mu-
cosal tissue.13 In addition, the poten-
tial for continued coronal creeping
of the soft tissue margin has been
reported to occur up to 1 year post
graft placement.14,15
Conventional mucogingival sur-
gery results in statistically better root
coverage and width of keratinized
gingiva. Roccuzzo et al16 and Oates
et al17 both concluded that a CTG
was statistically and significantly more
effective than GTR-based root cover-
age in recession reduction. Other
meta-analyses have drawn similar
conclusions, stating that additional
research was needed to identify the
factors most associated with success-
ful outcomes.18,19
The histologic nature of attach-
ment of the CTG to the root surface
is also important. It has been shown
to vary from true regeneration to a
fibrous adhesion to a long junctional
epithelium.2022 Although regenera-
tion would be preferred, it has not
been shown histologically that one
form of attachment is superior to
another.
A developing technique for
achieving GTR or repair to correct
bone dehiscence and fenestration
defects was described by Wilcko et
al.23 This technique was used to gain
bone height and volume in an area of
significant tooth proclination. Wilcko
et al24 also suggested that the use of
intramarrow penetrations increases
regenerative potential by increas-
ing blood flow to the graft material.
Frost25,26 first noted the healing po-
tential of surgical injury to osseous
tissue and the associated increase in
tissue reorganization. Later, Schenk et
al27 suggested that pluripotent stem
cells, found in the blood from areas
of intramarrow penetration (surgical
injury), can create a more favorable
osteogenic environment.
The objective of this study was to
treat areas of thin soft tissue and bony
dehiscences using hard and soft tissue
regeneration to provide a thick bio-
type and to prevent further recession.
Case history
A 26-year-old woman with a history
of orthodontic treatment presented
to Tufts University School of Dental
Medicine Department of Periodon-
tology, Boston, Massachusetts, for
consultation regarding mandibular
anterior labial root prominence and
gingival recession. The patient was
generally healthy and a nonsmoker.
The clinical examination revealed
good oral hygiene, a thin biotype,
and clinical probing depths ranging
from 1 to 3 mm. In addition, a 2-mm
labial gingival recession was noted at
both premolars and the left central
 21

Fig 1Initial (right) clinical photograph and (below) radiograph

showing the existing mandibular root prominence, gingival recession,
and bone loss at baseline.

incisor, and a 0.05- to 1-mm reces-
sion was observed at the canines and
remaining incisors. Inadequate at-
tached gingiva, 1 to 2 mm of papilla
loss, and significant root prominence
were also noted. Intraorally, root out-
lines and severe interradicular concav-
ities of the mandibular anterior teeth
were visible through the thin mucosal
tissue. At least 1 mm of interproximal
bone loss associated with the man-
dibular incisors was determined ra-
diographically (Fig 1). A diagnosis of
Miller9 Class I and III recession defects
was established.
The patient reported having dif-
ficulty maintaining this area because
of tooth sensitivity and soft tissue
discomfort when brushing. Because
of these concerns and the potential
for further progression, the decision
was made to alter the existing bony
architecture and soft tissue biotype.
The treatment plan included labial
GTR from canine to canine and sub-
epithelial CTGs from first premolar to
first premolar.

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22

Fig 2 After flap reflection, areas of bone dehiscence and fenestra- Fig 3 Decortication of the labial plate.
tion of the labial plate were noted.

Surgical technique No lingual flap was elevated. A muco-

Hard tissue augmentation
The patient was started on 500 mg
amoxicillin and a systemic corticos-
teroid (Medrol Dose Pack, Sandoz)
the day prior to surgery. Block anes-
thesia of the inferior alveolar nerve
bilaterally was obtained with a com-
bination of 2% lidocaine (Dentsply)
1:100,000 epinephrine and 0.5%
bupivicaine (Marcaine, Abbott Lab-
oratories) 1:200,000 epinephrine.
Local infiltration of the mental nerve
was obtained with 2% lidocaine
1:100,000 epinephrine.
A buccal sulcular incision, includ-
ing the buccal portion of the interden-
tal papillae, was made from the mesial
aspect of the first molar to the mesial
aspect of the homologous first molar.
periosteal flap was reflected beyond
the apexes of the teeth for access to
the entire defect. Teeth in the area of
the left canine through the right first
premolar were outside of the alveolar
envelope. Areas of bone dehiscence
and fenestration of the labial plate
were observed (Fig 2). There was a
3-mm dehiscence at the left canine,
a 5.5-mm dehiscence at the central
incisors, and a 6-mm dehiscence at
the remaining anterior teeth. A fen-
estration of 2 mm was present at the
right lateral incisor. Intramarrow pen-
etrations24 extended slightly into the
medullar bone and from the crestal
bone to the apical region. The intra
marrow penetrations were made
with a 0.25-mm carbide round bur
(Brasseler) and a high-speed hand
piece (Dentsply) with copious water

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 23

Fig 4 Placement of DFDBA over the root surfaces. Fig 5 Primary closure was achieved using a continuous sling pattern
to stabilize the flap.

irrigation (Fig 3). DFDBA (ACE Surgi-
cal Supply)7 hydrated with saline was
placed over the root surfaces to the
cementoenamel junction and into
the bone defects, extending beyond
the root apexes (Fig 4). The muco-
periosteal flap was then repositioned
passively.23 Suturing was completed
using 5-0 resorbable sutures (Vicryl,
Ethicon) and a continuous sling pat-
tern to stabilize the flap (Fig 5).
Postoperative instructions includ-
ed the application of cold packs for
the initial 48 hours postsurgery and
refraining from mechanical cleansing
of the surgical area for 4 weeks. The
patient was instructed to use 0.12%
chlorhexidine gluconate mouthrinse
(Zila Pharmaceuticals) two times per
day for 2 weeks and to continue the
amoxicillin and systemic corticoster-
oid prescriptions until completion.
After 4 weeks, the patient began
gentle tooth brushing and flossing.
Postoperative visits were completed
at 2 and 4 weeks and 2, 3, and 6
months. The sutures were removed
at the 2-week follow-up. Prophylaxis
was provided as needed. Postopera-
tive healing was uneventful.
Reentry/soft tissue augmentation
At the 6-month follow-up, there was
a thickening of the labial tissue pro-
file (Fig 6). A systemic corticosteroid
was started the day prior to reentry
surgery. Anesthesia was administered
in the same manner. In addition, a
bilateral greater palatine nerve block
was obtained with a combination of
the same anesthetics.

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24

Fig 6 Clinical view at the 6-month reentry. Fig 7 Mucoperiosteal flap reflected for a subepithelial CTG. Bone
augmentation was noted clinically.

The exposed root surfaces were
prepared using hand instruments
and a Cavitron SPS ultrasonic scaler
(Dentsply). The same incision design
was followed. A mucoperiosteal flap
was reflected beyond the mucogin-
gival junction (Fig 7). Clinically, there
was horizontal and vertical regenera-
tion of the labial plate; 2 mm of bony
root coverage was achieved at the
lateral incisors and the left central in-
cisor and 3 mm was achieved at the
right canine. No coverage was
achieved on the left canine or right
central incisor. The dehiscence of the
right central incisor appeared narrow-
er than first noted. This tissue was
firmly attached to the root surfaces
and appeared well-vascularized. Non-
integrated bone particles were ob-
served both on the surface of the
integrated graft and encapsulated
within the flap.
Subepithelial CTGs were harvest-
ed bilaterally from the palate using
the single incision technique.12 The
resulting CTGs were approximately
30 5 1.5 mm. Absorbable col-
lagen wound dressing (Collacote,
Zimmer) was trimmed, hydrated with
saline, and placed into each donor
site. The donor sites were sutured
with 5-0 resorbable sutures with an
interrupted horizontal x-type pattern.
Periosteal releasing incisions were
made beyond the mucogingival
junction to allow for coronal flap ad-
vancement over the sutured CTGs.12
The grafts were sutured over the pre-
pared root surfaces and surrounding
bone with 5-0 Vicryl continuous sling
sutures (Fig 8). The flap was passively
positioned at or above the cemento
enamel junction and sutured with 5-0
resorbable sutures using a continu-
ous sling pattern (Fig 9).
Postoperative instructions, suture
removal, and prophylaxis were per-
formed as discussed previously. No
antibiotic was used for this surgery.
Results
In general, postoperative healing
was uneventful. Patient discomfort
was minimal in both donor and re-
cipient sites.
At the 2-month soft tissue graft
postoperative visit, complete root
coverage almost was achieved. The
left central incisor exhibited 1 mm
of recession. There was a 2-mm gain
in labial soft tissue thickness, but
no visual difference in the height of
keratinized tissue. The procedures
eliminated the interradicular concavi-
ties; however, interdental soft tissue
craters were present. The patient

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 25

Fig 8 CTG sutured over the prepared root surfaces. Fig 9 Primary closure was obtained over the graft.

was able to maintain the grafted area
comfortably with routine oral hygiene
practices, and a significant clinical
gain in tissue thickness was noted.
At the 1-year soft tissue graft
postoperative visit, complete root
coverage was maintained at the lat-
eral incisors and canines, while ap-
proximately 1 mm of recession was
present at the central incisors. The
interdental soft tissue craters had
resolved with no additional papil-
lary loss between the central and
lateral incisors. The soft tissue width
and height were maintained, and
the interradicular concavities were
eliminated. The patient reported no
discomfort and indicated that the
area was maintainable with routine
oral hygiene practices.
At 3 years postsurgery, the area
appeared stable with no clinical at-
tachment loss, and probing depths
were consistent with pretreatment
measurements. Also, there appeared
to have been a slight coronal creep
of the soft tissue margin labial to the
central incisors, with maintenance of
a stable band of keratinized mucosa
and clinical reestablishment of a mu-
cogingival junction. Patient comfort
during function and routine oral hy-
giene was maintained (Fig 10).
Discussion
Reestablishment of an ideal anatomi-
cal architecture following orthodontic
tooth movement often involves both
hard and soft tissue augmentation.
This is usually a result of the labial
movement of teeth outside of the en-
velope of the arch. Augmentation of
bone volume can correct the associ-
ated root dehiscences, and alteration
of the gingival biotype will allow for
greater compliance with oral hygiene
and create an environment less likely
to be affected by plaque-induced in-
flammation. Hard and soft tissue aug-
mentation also addresses esthetic
concerns by providing more harmo-
nious contours, and can also reduce
the problem of root sensitivity. Cor-
rection of these defects may require
multiple surgeries to produce a sig-
nificant benefit.
The results of this report were
representative of the overall conclu-
sions drawn from the studies cited.
DFDBA was used because of the
suggested osteoinductive potential
of the bone morphogenic proteins
it contains.7 A clinical gain of 2 to
3 mm in bone thickness and height
in almost all defects was noted and
further supports the use of DFDBA
to stimulate bone formation. The

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26
results also suggest that DFDBA
stimulates bone formation when a
full-thickness mucoperiosteal flap is
chosen as the membrane.23 The flap
was elevated beyond the apexes of
the teeth for complete visualization.
Graft placement in this manner may
be a limiting factor because of the
somewhat impaired ability to con-
tain and stabilize particulate graft
material. More ideal graft contain-
ment may have allowed for addi-
tional bone formation and defect
resolution. Intramarrow penetrations
allow for greater vascularization of
the graft material and the efflux of
pluripotent stem cells, which can
help create a more favorable os-
teogenic environment. They also
provide a source of insult to the os-
seous tissue, which may trigger an
increase in reorganizing activity.27
Although clinical bone regenera-
tion is evident, histologic evidence
of bone formation and the nature of
the attachment to the root should
be included in future studies.
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Fig 10 Three-year follow-up clinical photograph.
Long-span connective tissue graft-
ing is more challenging for the pa
tient and surgeon. Additional surgical
wounds increase the chance for post-
operative discomfort. Also, the donor
site may not allow for the amount of
tissue needed for regeneration. Com-
plete root coverage of all treated
teeth almost was achieved, except for
the central incisors, which exhibited
approximately 90% root coverage.
These results parallel the success rates
of the subepithelial CTG procedures
presented in the studies cited.
There also was a clinical altera-
tion of this area, which more closely
resembled a thick biotype. However,
this study failed to use tissue cali-
pers to record tissue thickness, which
may have allowed for a more exact
measurement of posttreatment tissue
thickness gain. The clinical reestab-
lishment of a visible band of keratin
ized mucosa suggests that palatal
coreum, or connective tissue, con-
tains the cells responsible for epithe-
lial tissue keratinization.13
Suturing also plays a crucial role
in successful root coverage. Constant
passive tension must be maintained
when using sling-type sutures. Loss
of tension may be a reason for the
less than complete root coverage at
the left central incisor. Although, Har-
ris14,15 discussed the potential for tis-
sue to creep, as well as suggesting
that mean root coverage continues to
increase with time. This may explain
the additional root coverage of the
left central incisor, which was present
at 1 and 2 years postsurgery.
The suggested level of evidence
provided by a single case report and
the short follow-up period are limi-
tations of this study. Further, there
is an inadequate amount of avail-
able literature regarding GTR using
a bone graft, which compares use of
a membrane when treating recession
defects to not using one. Further ran-
domized controlled clinical trials com-
paring graft material with or without a
membrane when treating recession
defects are needed to determine the
long-term clinical significance.

Acknowledgments
The author gratefully acknowledges Drs Timo-
thy Hempton, Walter Meinzer, and Hide Moroi
for their invaluable dedication to the Tufts De-
partment of Periodontology residents, as well
as Drs Anna and Daniel Spencer for their com-
mitment to the success of this report.
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